=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275725996
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE HEALTHCARE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2007
-----------------------------------------------------
Last Update Date | 09/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 FOOTHILLS DR STE B
-----------------------------------------------------
City | MORGANTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28655-5123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-580-8000
-----------------------------------------------------
Fax | 828-580-8010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 601076
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-580-8000
-----------------------------------------------------
Fax | 828-580-8010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP-CFO
-----------------------------------------------------
Name | MR. ROBERT G FRITTS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-580-5545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------